Recovery – from schizophrenia symptoms to well-being

Recovery in an important focus in the treatment and management of schizophrenia but what exactly is recovery and how can it best be attained? Indeed, from whose perspective has recovery occurred as clinicians’ and patients’ criteria may sometimes differ. An interesting symposium at EPA 2018 looked at some of the various factors that influence recovery and gave suggestions as to how best it can be achieved.

Professor Michaela Amering, Vienna, Austria, explained that recovery is currently health policy in the USA, Canada and the UK and is generally agreed to mean the ability of patients to live a satisfactory life even with the limitations caused by their illness.

Recovery - the ability of patients to live a satisfactory life even with the limitations caused by their illness

However, recovery from mental illness can mean more than recovering from the illness itself. Patients also have to recover from the effects of stigma, from iatrogenic effects, from lack of employment opportunities and possibly most importantly from crushed dreams. How can patients be best helped to overcome these related effects of their illness?

Treatment gap

Most believe that recovery is a basic civil right but, in this day and age of scarce resources, it is important to ensure that any adopted strategies are cost-effective which, in turn, means relying on evidence-based study recommendations. However, only 25% of patients with serious illness attain recovery following use of some evidence-based strategies. Clearly, there is a treatment gap. Patients’ views of what they found most helpful and what they most need when being treated, particularly the views of those patients who have recovered, should be taken into consideration when making policy decisions.

Only 25% of patients with serious illness attain recovery

Harmony

Clinical intervention can have unwanted side effects, sometimes impacting on treatment adherence. What seems clear is that treatment decisions - individual, institutional and global - should to be taken most definitely with patients’ involvement and collusion if the goal of recovery is fully to be attained.

Patients’ involvement in policy making is key if the goal of recovery is to be attained

Professor Armida Mucci, Naples, Italy, reiterated that the implementation of recovery-orientated treatment plans requires an in-depth understanding of key factors influencing real-life functioning of people with schizophrenia. However, the identification of such key factors is not straightforward.

Networking – neural and otherwise - in schizophrenia

Professor Mucci outlined a data-driven, neural network analysis of data gathered from 740 patients with schizophrenia living in the community the findings of which have substantial treatment implications. For example, it appears that positive symptoms do not play a key role in the chain of factors leading to real-life functioning. Furthermore, the pattern of network node connections supports the implementation of more personalized interventions in schizophrenia. Thus, the central placement of functional capacity and every-day life skills within the network suggests not only that improving patients’ abilities to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia but that recovery-orientated approaches should focus more on basic functioning goals than on symptom control.

Improving patients’ abilities to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia

Adherence is cost-saving

Professor Philip Gorwood, Paris, France, spoke about adherence in schizophrenia. As he explained, adherence is a problem in schizophrenia and any plan to improve recovery needs to take this into account. Not only does poor adherence increase the risk of relapse it also increases costs, most importantly, hospitalization costs. As he stated, investing in adherence will be cost-saving.

Investing in adherence will be cost-saving

A number of factors associated with poor adherence can already be addressed by clinicians. Ensuring patients work with and trust their physicians to agree treatment plans is one factor. Offering therapeutics with fewer side-effects is another and giving patients better insight into their disease and enabling more positive attitudes can also influence adherence. Poor insight should be considered as a symptom of schizophrenia as it correlates with cognitive skills deficit, in Professor Gorwood’s opinion.

Suggestions for improving adherence include:

improving patient insight,

focus on strengthening therapeutic alliance,

focus on the positive aspects of the medication,

patient/family psychoeducation,

emphasize short term (reduction of symptoms) and long-term (relapse prevention) benefits of adherence to medication,

educate patients about medication and potential side-effects,

include patient preference and needs when designing the treatment regimen,

simplify the therapeutic plan including the use of second-generation antipsychotics Long Acting Injectables (SGA LAIs).

Social functioning is an important treatment goal

Social functioning is severely damaged in schizophrenia with consequences for both the patient and families. It is also recognized as an important treatment goal. However, its assessment is not straightforward as a recent study by Karow et al. 2012 showed. In this study, assessment of functional remission tended to be overly optimistic, regardless of assessor – physician, patient or carer. What was slightly concerning was that, subjectively, carers could detect remission better than the clinicians. What in reality this means is that clinicians need to supplement their social functioning assessments to include patient and carer’ perspectives.

Mini-FROGS

Cognitive factors, insufficient disease insight and not living within the family are the top three reasons for hospitalization in four European countries. As insufficient disease insight and not living within the family reflect poor functioning, assessing functionality is important in clinical practice. However, doing so can be time consuming. With this in mind, Professor Gorwood described the mini-FROGS (Functional Remission of General Schizophrenia) scale which can be administered in a single 5-minute face-to-face assessment. This 4-item condensed version of the original FROGS tool correlates with the quality of life scale (QLS), quantitatively and qualitatively reflecting clinical remission. It captures most of the benefits that can be translated into everyday functioning and clinical remission:

Travel and communication

Management of illness and treatment

Self-esteem and sense of independence

Respect of biological rhythms

mini-FROGS can be administered in a single 5-minute face-to-face assessment

In conclusion, if patients are involved in their treatment and recovery programs, this increases the chances of recovery and improved functional remission.

Gorwood P. (2011). Factors associated with hospitalisation of patients with schizophrenia in four European countries. European Psychiatry, 26(4), 224–230.

Mallet J, Lancrenon S, Llorca PM, Lançon C, Baylé FJ, Gorwood P. (2018). Validation of a four items version of the Functional Remission of General Schizophrenia scale (the mini-FROGS) to capture the functional benefits of clinical remission. European Psychiatry, 47:35-41.

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